My Child Just Received A Borderline Personality Disorder Diagnosis- Is This Forever?

Can I Even Help Them?

So what do we know about those who have a borderline personality disorder diagnosis? Well, in general, they tend to be women or trans, many of whom consider themselves queer/LGBT+, are often adopted or spent time in foster care, and/or experienced some form of trauma in childhood; however, this is not always the case and does not describe all people who have BPD. So what do the facts say? Well, while it is true that slightly more women than men are diagnosed with BPD, it is not as much of a discrepancy as one may have guessed, as the ratios are approaching 50/50 in recent years. There is a correlation between the queer/LGBTQ+ community and BPD (up to 40%). And similarly, up to 40% of adolescents with BPD have experienced adoption/foster care (typically an interaction between genetic vulnerability, prior environment, and lack of attachment to bio or adoptive parents). Both of these groups often struggle to form their own identity, especially during adolescence, and expect that no one can love/accept them if their biological parents didn’t. Sadly, more than 70% of those with BPD had at least one traumatic event during childhood and 8% of those with severe BPD have experienced sexual or physical  abuse by their parents. But within both these groups, there lies kind of a chicken or the egg situation (as these children are often rejected, bullied, invalidation, abused) because of the complex relationship with identity disturbance and coping with all of these traumatic and life-altering experiences. Additionally, approximately 40% of those who were diagnosed with a behavioral disorder (ADHD, ODD, DMDD) during childhood end up being diagnosed with a personality disorder as adults, which may suggest a genetic or neurobiological vulnerability. Often, interactions between genetic vulnerability of traits and early developmental trauma can be exacerbated by parental rigidity, lack of empathy, blaming the child, and/or parents always feeling they are right. The term “borderline” originated in the 1960s, thought of as intersection between neurosis and psychosis but the term also results in confusion and stigma. Though no specific neuroanatomical or neurochemical causes have been identified, there may be frontal lobe, limbic, and corpus callosum involvement, as well as a hypersensitive neurobiological system, including increased dopamine (which overlaps with ADHD, PTSD etc). Moreover, 85% of those diagnosed with BPD meet criteria for at least one other diagnosis, most often: PTSD, ADHD, reactive attachment disorder (RAD), substance use disorder (SUD), depression, and eating disorders. As such, it begs the question, are there possibly “pre-requisites” so to speak, including: history of trauma/rejection, average to higher IQ, history of behavioral/neurodevelopmental disorder, and differences in sensory/pain experiences?

Perhaps more importantly, misdiagnosis can result in unnecessary hospitalizations and/or medication, as well as mistrust of doctors. Many are misdiagnosed with bipolar disorder, other personality disorders, or even psychosis. Moreover, delayed diagnosis can result in DEVASTATING outcomes. Fortunately, we can now diagnose adolescents, as new criteria and more research have shown that BPD emerges earlier, is pervasive and requires early intervention. BPD can be diagnoed in adolescents when there is a 1-year pattern of immature personality development with disturbance in at least 5 of the following: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal or self-mutilating behavior, affective instability, chronic feelings of emptiness, inappropriate/intense anger, stress-related paranoid ideation.

As I mentioned, there is quite a significant stigma surrounding borderline personality disorder. There label of borderline is often used as an insult, even though many with BPD have undergone significant trauma. People who genuinely have BPD are often labeled as attention-seeking and manipulative, though it’s not so much manipulation but lacking skills and trying to get needs met. Adoptive parents often blame themselves, even though they likely had little to no control over whether or not their child ultimately developed borderline personality disorder. The stigma is also reinforced by film/TV and books, as many past books written about BPD have stigma within their titles (e.g., hard to love, I hate you-done leave me, walking on eggshells).

So then what is the real and genuine experience of adolescents and young adults with BPD? For those who experience trauma and or rejection, this “emotional loss” often results in “complete hopelessness.” Many experience real or perceived rejection or lack of emotional intimacy from parents. Many grow up in “invalidating environment” with erratic behavior of their parents/caregivers, resulting in insecure attachment. As a result of these developmental experiences, many experience mood lability, difficulty in relationships, poor self-image, impulsivity, and poor identity formation. Per the accounts of those with BPD, it often feels confusing, powerless, exhausting, and lonely. Some also feel trapped or confined by their emotions. Some have expressed that BPD feels like “punishment for being abused” and the resulting rejection/mistreatment feels like re-traumatization. Unfortunately, many with BPD engage in self-destructive behaviors (substance use, truancy, disordered eating) to deal with anguish and distress. Some can experience dissociation, hallucinations, or stress-induced seizures. Often for people with BPD, their behaviors are often the opposite of what their true wish is (e.g., avoiding/ignoring friends while desiring closeness, giving up academically/vocationally but wishing to be successful, hurting themselves instead of directing hurt towards those who hurt them). Black and white thinking, reduced flexibility, and lack of balance in behaviors/thoughts can be prominent. Adolescents often show a deep self-loathing may describe “blacking out” with rage. Adolescents with BPD may also engage in risky and self-destructive behaviors to cope or seek validation from others, and as a result, may be vulnerable on the internet because of potential for risky behaviors, attention-seeking, and information sharing, as others may see them as easy targets to take advantage of. Moreover, the internet can also further promote self-injury and promiscuity, may react poorly to perceived reality on social media (FOMO, rejection sensitivity, competition, cyberbullying etc).

In terms of interpersonal relationships, there can be massive vacillations between idealization (this person is the best) and devaluation (this person is awful and the worst) because of unobtainable standards for themselves and others. They will often have a “favorite person” that they tend to rely and/or co-regulate with, as they often rely on others to solve problems as opposed to solving themselves. People with BPD tend to respond to unpredictability/breaking of trust by world or others with unpredictability of behavior and untrusting of world and others. They also tend to blame others for their behaviors and expect to be abandoned so require constant reassurance from others. They may be triggered by friends, family, or partners setting boundaries or not providing the desired or expected responses via text, social media, or in person. There is a perpetual fear of rejection that can become a self-fulfilling prophecy.

The most concerning and distressing “symptom” of BPD is self-harm and suicidal behavior. Per one statistic: up to 1/10 will die from suicide and/or self-destructive behaviors and up to 90% with BPD will attempt suicide at some point. About 6% of teens have admitted to self-injuring on a regular basis. Those who cut/self-injure have 300x more risk of suicide attempts, even if initial self-injury is not an actual suicidal attempt. Most parents have no idea their child was cutting for months or years before it was discovered, even if there have been unexplained scars, cuts, and burns, as they will often make excuses for injuries and/or wear unusual clothes or make-up. Many hoard sharp objects or spend excessive time in their room or shower alone. Cutting often the result of feeling broken, wanting a release, feeling they deserve it, means to control, report not feeling much pain and feeling more alive (non-BPD adolescents may copy others or seek attention for different reasons but feel pain and no release), solution to a problem but don’t see it as a problem in itself. Those who have reduced suicidal/self-injury tend to have increased family connectedness and reduced judgement.

Before I discuss the therapeutic interventions for BPD, I think it is important to discuss the caveats and barriers to therapy for those with BPD. Many will be turned away from help/therapy just because of their diagnosis. Many clinicians feel clients with BPD are a liability because of high suicide risk, threats/manipulation, or treatment resistance. Many who do not get better don’t have access to the right specialists (untrained, biased etc). As a result, it is crucial to have a therapist with long-term training and access to a DBT consult team. On the other side of things, many adolescents will refuse to participate in therapy initially, especially if not DBT or a related therapy, though they may go if their motivation is to “get their parents off their back.” As parents, it may be helpful to make it clear that therapy is for your child and not for you, as many teens have actually reported enjoying the group aspect of DBT. It is important that a child’s BPD diagnosis does not remove responsibility or free will of behavior.

In terms of the most effective therapies for BPD per both the research and anecdotal reports, the first and most well-known is DBT, or dialectical behavior therapy. In DBT it is taught that emotions are like “waves to be ridden” and to engage in radical acceptance of not being able to control self/world/others. The goals of DBT are acceptance and behavioral change, using wise mind (emotion and reasonable minds combined), validation, and distress tolerance, to create emotional balance, and productive interpersonal relations. Clients are encouraged to avoid “shoulds” and feelings things are “unfair”, to keep their attention on the present (one thing at a time) and be direct in relationships. They are also encouraged to assess if their assumptions are true and if their reactions were justified. It is recommended that they try to engage in opposite action of urge (urge to sleep- get up and exercise, urge to scream- start writing/journaling, urge to drink alcohol- drink tea etc.) in order to make their actions fit long term goals and evaluate actions following a distressing situation. Other recommended strategies include: new hobbies, a cold shower, exercise, weighted blanket, walk pet, listen to music, call a friend etc. (even if much harder to do). DBT requires both individual and group sessions and phone and text support is provided as needed. When doing DBT with teens and their parents, a goal is to get the parents to understand the child’s perspective and why they engaged in the particular behavior. Those in DBT therapy have a significantly lower risk of suicide, learn to tolerate distress without self-injuring and to self-advocate to ensure safety.

Another therapy intervention that has gained a lot of traction is MBT, or metallization-based therapy. The premise is that behavior is influenced by mental states and the goal is to understand others’ perspectives and not make assumptions with lack of facts. Other goals include reducing catastrophozing and mind reading, as well as suicidality and self-harm behaviors. It is intended to stabilize sense of self, teach self-regulation and perspective-taking. The main message is that two things/perspectives can be true and that it is often necessary to separate between perspectives and positions but need to appreciate that both have valuable aspects. Next is transference-focused psychotherapy, which explores thoughts/feelings from childhood, relationship between client and therapist important to work through past traumas, very structured and frequent therapy. Similar to transference-focused psychotherapy is schema-focused therapy, which posits that schemas are flawed because of unmet needs from childhood, uses a warm attachment with therapist to create new healthy schemas. Overall these two therapies are very similar, but transference-focused psychotherapy is more psychodynamic and schema-focused therapy is more of a combination of cognitive and psychodynamic, with some “reparenting” by clinician. And finally, system training for emotional predictability and problem-solving, or STEPPS is a group-based treatment for emotional regulation, intended to be a supplement to individual therapy, provided psychoeducation for all family members, goal is to teach family common language to be able to communicate clearly and use skills effectively

Aside from these more structured therapeutic programs, some require psychiatric care and/or more intensive psychological care in conjunction. In terms of medications- there are no specific medications intended to treat BPD specifically; however, many people with BPD are prescribed some combination of SSRIs/SNRIs, atypical antipsychotics, and/or benzodiazepines. Some children may benefit from intensive outpatient programs (IOPs) or partial hospitalization programs (PHPs), which are essentially a step-down from inpatient hospitalization. Some may require additional care via a Residential Treatment Center but as parents, it is essential you ensure it is properly vetted by yourself and trusted clinicians with significant family involvement and access to your child at any time. 3EAST at Mc Lean Hospital in Massachusetts (Harvard), which has one of the country’s top BPD Wings.

On a very positive note, recovery is very much possible and realistic with treatment, especially for those who are diagnosed and receive intervention at a young age. It used to be that 25-33% would “recover” within 10 years from diagnosis, but now up to 85% recover in 10 years and 20% recover in only 1 year. And most positively-suicidal ideation and self-harm are usually the first to improve. In fact, it has been well documented that “recovered” BPD individuals often make great therapists. Overall, In order to obtain true and long-lasting success, people with BPD require safety, respect, genuineness, and trust are key from therapist, friends, and family.

For parents: it can be very helpful to share the BPD diagnosis with your child and to have the information come from you as opposed to elsewhere. It is important not to minimize distress/effects of BPD and don’t blame anyone. Of course it is ultimately the parents’ choice whether or not to disclose the diagnosis to others (e.g., family/friends); however, you should know there is a possibility of poor responses from the child (potentially feeling violated) and others who are not educated about the diagnosis. It is helpful to understand motivations, wants, and needs of the underlying emotions of your child. Validation communicates acceptance, understanding, and love and can ultimately teach a child to self-validate. Validation from parents/family is most important for teens, but validation doesn’t mean permission for self-destructive behaviors. Try not to either minimize or overreact to behaviors. If parents ask clarifying questions and set emotional boundaries it may reduce opportunities for “manipulation. Children with BPD require balanced limits and consequences, in addition to freedom, privacy and independence (even if suicidal these are still important but may look different). If your child is using alcohol/drugs, try to find out why and set realistic limits/expectations and be consistent and direct. Harsh punishments often backfire with children with BPD but they do need consequences with consistency.” Anger or frustration on the part of parents can reinforce perceived rejection/punishment so it is important that parents respond with empathy and validation. It is important to know that parents cannot remove trauma from their child’s life prior to their adoption even if they “do all the right things.” Many parents want to understand why their kids have BPD but they often don’t receive answers, need to accept that and focus on supporting them. Parents need to accept their kids with BPD as they are, love them unconditionally, and let go of their own expectations. Remember to remove anything from the home that can be used for self-harm or suicide. If your child cuts: consider getting them a tetanus shot, began therapy, don’t judge or overreact, and bring to doctor or hospital if significant injury/infection. Most importantly, NEVER dismiss suicidal ideation, there is always a reason.

For those who experience BPD themselves, know that you cannot treat yourself with compassion if you do not feel worthy. It is helpful to understand the functions of negative behaviors in reaction to negative feelings (anger, frustration, anxiety, guilt, envy). Validate your own feelings and notice without judging yourself or others, describe instead of judging and then align your true values with your actions. When upset, try to limit time of avoidance and withdrawal and try not to avoid the negative feelings, take accountability, accept mistakes, work towards a goal, seek those who can provide unconditional support, cannot solve all problems. For relationships, it is important to lead with openness and honesty with platonic and romantic relationships. Set limits and boundaries instead of people pleasing and feeling guilty. If you feel suicidal ideation creeping up, it can be helpful to visualize loved one or pet watching you self-harm to deter from act, but always reach out to your therapist or a trusted loved one if you feel unsafe or cannot stop yourself from self-harming or other self-destructive behavior. And finally, though the internet can be dangerous in some respects, it can also provide positive support groups and psychoeducation fro young adults and parents/caregivers. In fact, some groups have “sponsors” to ensure safety and try to prevent suicidal attempts. Some helpful websites include: Sashbear foundation, BPD Alliance, and New York Presbyterian BPD Resource Center.